Understanding Post-Hemorraghic Stroke: Will Confusion Ever End?

Hemorrhagic stroke is a life-threatening condition caused by bleeding into the brain or the space between the brain and its outer covering layer. This bleeding can be a result of a ruptured blood vessel or other factors such as blood vessel abnormalities and blood disorders. The condition is associated with severe morbidity and high mortality, and early diagnosis and treatment are crucial to prevent permanent brain damage or death. Confusion is a common side effect of strokes, affecting memory and thinking ability, and can last for varying durations in patients. The treatment for confusion aims to provide patients with tools to manage their daily lives better and includes occupational therapy and, in some cases, clinical neuropsychology.

Intracerebral haemorrhage

The most common cause of ICH is high blood pressure (hypertension), especially if it is very high or uncontrolled. Other risk factors include amyloid angiopathy, the use of blood thinners, and vascular malformations. ICH typically occurs in people over 55, and it is more common in men and certain racial groups, including African Americans and Asians.

The symptoms of ICH can vary depending on the severity, timeframe, and location of the bleed. However, common symptoms include headache, nausea, vomiting, alterations in consciousness, and weakness or numbness in the face, arm, or leg.

ICH is typically diagnosed using a non-contrast computer tomography (CT) scan, which can reveal the extent of the bleed and any surrounding edema or increased intracranial pressure. Treatment focuses on stopping the bleeding, removing the clot, and relieving pressure on the brain. Non-surgical treatments include administering clotting factors and controlling blood pressure and intracranial pressure. Surgery may be considered for patients under 50 or those with a favourable location for surgical evacuation.

ICH has a high mortality rate, with about 44% of those affected dying within a month. The prognosis depends on the size and location of the hematoma, as well as the patient's age and overall health. Early diagnosis and treatment are crucial for improving outcomes.

Subarachnoid haemorrhage

A subarachnoid haemorrhage is a type of stroke caused by bleeding on the surface of the brain. It is a very serious condition that can be fatal. It occurs when a weak area in a blood vessel (aneurysm) on the surface of the brain bursts and leaks. The blood then builds up around the brain and inside the skull, increasing pressure and causing brain cell damage, lifelong problems, and disabilities.

The symptoms of a subarachnoid haemorrhage include:

• A sudden, severe headache, unlike anything experienced before, often described as a "thunderclap".
• Loss of consciousness, which may be brief or prolonged.
• Confusion and trouble concentrating.
• Sensitivity to light (photophobia).
• Blurred or double vision.
• Stroke-like symptoms such as slurred speech and weakness on one side of the body.
• Nausea and vomiting.
• Convulsions (uncontrollable shaking).

Medications are typically administered to prevent short-term complications, and a procedure to repair the source of the bleeding may be performed. Surgery may be required to place a small clip or stent on the blood vessel to stop the bleeding.

Complications of subarachnoid haemorrhage can be both short and long-term. Short-term complications include further bleeding at the site of the aneurysm and brain damage caused by reduced blood supply. Long-term complications include epilepsy, problems with memory, planning, and concentration, and changes in mood, such as depression.

While the outlook for subarachnoid haemorrhage has improved in recent decades, it remains a serious condition that can be fatal. Recovery can be slow and challenging, and survivors often experience long-term issues.

High blood pressure

Hypertension can lead to hemorrhagic strokes by damaging blood vessels inside the brain, causing them to rupture and bleed. This bleeding puts pressure on the surrounding brain tissue, damaging or destroying it.

The risk of a hemorrhagic stroke is higher for people with longstanding hypertension, which can cause degeneration of the media, breakage of the elastic lamina, and fragmentation of smooth muscles in arteries. This can lead to lipohyalinosis, fibrinoid necrosis of the subendothelium, the formation of microaneurysms, and focal dilatations in the arterioles.

Brain aneurysms

A brain aneurysm, or cerebral aneurysm, is a weak or thin spot on an artery in the brain that balloons or bulges out and fills with blood. Aneurysms can develop in any blood vessel in the body, but they most commonly occur in the abdominal aorta (the artery that transports blood away from the heart to the rest of the body).

Most brain aneurysms only cause noticeable symptoms if they burst (rupture). A ruptured brain aneurysm is a medical emergency and can lead to an extremely serious condition known as a subarachnoid hemorrhage, where bleeding caused by the ruptured aneurysm can cause extensive brain damage and symptoms. Symptoms of a ruptured brain aneurysm include:

• A sudden, agonising headache, often described as a "thunderclap headache".
• Sickness and vomiting.
• Pain when looking at light (photophobia).
• Loss of consciousness.
• Seizures.
• Paralysis on one side of the face.
• Vision changes or double vision.

If you experience any of these symptoms, it is important to seek immediate medical attention.

Not all brain aneurysms rupture, and most go undetected until they either rupture or are detected during imaging tests for other medical conditions. However, if a brain aneurysm is detected before it ruptures, treatment may be recommended to prevent it from rupturing in the future. The risk of rupture is influenced by factors such as age, the size and position of the aneurysm, family medical history, and other health conditions.

There are several treatment options for brain aneurysms, including:

• Filling the aneurysm with tiny metal coils (coiling).
• Open surgery to seal the aneurysm with a tiny metal clip (surgical clipping).
• Microvascular clipping, which involves cutting off the blood flow to the aneurysm.
• Endovascular treatment, such as platinum coil embolization, which is a less invasive procedure than microvascular surgical clipping.
• Flow diversion devices, which involve placing a small stent in the artery to reduce blood flow into the aneurysm.

It is important to note that brain aneurysms can be life-threatening, and early diagnosis and treatment are crucial to improving outcomes.

Brain tumours

A brain tumour is an abnormal mass of tissue in which cells grow and multiply uncontrollably, unchecked by the mechanisms that control normal cells. There are over 120 different types of brain tumours, making effective treatment very complicated. Brain tumours are either primary or metastatic. Primary brain tumours originate from the tissues of the brain or its immediate surroundings, whereas metastatic brain tumours arise elsewhere in the body and migrate to the brain, usually through the bloodstream.

Primary brain tumours are further categorised as glial or non-glial and benign or malignant. Glial tumours are composed of glial cells, which are the supporting cells of the brain. Non-glial tumours develop on or in the structures of the brain, including nerves, blood vessels and glands. Benign tumours are non-cancerous, whereas malignant tumours are cancerous.

Metastatic brain tumours are considered cancer and are always malignant. They affect nearly one in four patients with cancer, or an estimated 150,000 people a year. Up to 40% of people with lung cancer will develop metastatic brain tumours.

The most common type of primary malignant brain tumour is glioblastoma. Even with aggressive treatment, the average survival rate is less than one year. The most common type of benign brain tumour is meningioma, which accounts for about 30% of brain tumours. Meningiomas originate from the meninges, the membrane-like structures that surround the brain and spinal cord. They are often benign and may not require surgery.

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